The unpalatable truth about ethics committees

Daniel Sokol’s approach is more moderate in his response. But he
appears to stand by his view (BMJ 2009;339:b4179) that Clinical Ethics
Committees (CECs) “alone … are not the answer to the day to day dilemmas
faced by clinicians.” Of course they are not. But nor is what he
proposes.

Quite apart from the acknowledged low response rate in the Sokol
study, his quantitative findings seem disconnected from his conclusions.
The number of CECs that are “moribund” is, by his own data, quite small.
A low referral rate does not justify the claim, quoted by Sokol from his
earlier work, that “clinicians are not using them.”

Clinicians are using our CEC. It is approaching its fourth birthday
having endured two rounds of organisational change, battled for
credibility and funding, relied entirely on the goodwill & capability
of the officers’ secretaries, met in dingy rooms on dark evenings and
occasionally sat twiddling its thumbs and wondering why no one has made
referrals. It has a broad range of experience and expertise including a
handful of postgraduate degrees. That breadth and plurality, if well
used, makes for vigorous debate and produces advice that is far more
robust than a single expert ever can, avoiding domination by a single view
or approach. It has engaged, sometimes quickly via email subcommittees
and sometimes contemplatively in a quarterly full meeting, with
experienced clinicians struggling with real dilemmas. In the last two
months they have included potentially headline-hitting controversies. The
CEC has never claimed to have easy answers but has consistently helped
those clinicians to find a way through the mire. We have a sheaf of
‘thank-goodness-for-the-CEC’ emails to show for it and increasing demand
from disciplines who have not used us before. Far from just showing how
well we've done, this demonstrates the usefulness and stability of a model
of clinical ethics support that Sokol would replace with a different
approach.

Are there dilemmas that don’t get referred? Are there colleagues who
don’t even know we exist? Of course there are. Are there people who are
too intimidated to refer? Yes, although in our case it’s not because
we’re scary but because they fear conflict within their team if they go
outside the chain of command. I don’t think we’ll have arrived until we
get referrals from GP practice staff worried about confidentiality at the
reception window. But there is a reason that British CECs have low demand
and don’t need to offer emergency advice. Most clinicians are good at
integrating the ethical into their clinical decision-making, have access
to authoritative published guidance, and only occasionally need help. I
don’t often need a plumber, but when I need one I’m really glad to find
one.

Putting 24/7 ethics consultation into hospitals is like having the
plumber living in your house. You’ll get him to turn the taps on and off
for you. Eventually there’ll be health and safety rules banning you from
touching them. This is the unhappy reality in a culture that insists on
ethical review of every hard decision, a culture that as reported above
exists in only a minority of hospitals even in the US. The real ethical
decision makers where I work are the clinicians, and the CEC is glad not
to have deskilled them but to be in support when it’s needed. What is the
answer to clinicians’ ethical dilemmas? It lies in better training,
clearer guidance, and fewer organisational barriers to reflection on hard
choices and to doing their best with their patients. All CECs need to
keep improving. But the only ones who would gain from Sokol’s proposals
are the ethicists.

Competing interests:
I chair a CEC.